Video-assisted Mediastinal Lymphadenectomy Research Articles

MID­term results of the urgent right lung complex reconstructive tracheobronchial resection in a patient with exacerbated central lung cancer (clinical case)

Introduction. Treatment of patients with central non-small-cell lung cancer (NSCLC) complicated by recurrent hemophtysis is an urgent problem in oncology and thoracic surgery. The aim of this study is to demonstrate the possibility of performing radical organ-preserving surgery (right upper lobectomy with resection of the carina) in a patient with central NSCLC complicated by life-threatening pulmonary hemorrhage. Material and methods. A 64-year-old patient was hospitalized in our thoracic surgery department with grade IB hemophtysis for emergency indications. According to the results of the examination and data from rigid bronchoscopy, an infiltrative peribronchial tumor of the right upper lobe bronchus spreading to the right main bronchus, intermediate bronchus and distal trachea was revealed. According to vital indications, the patient underwent video-assisted mediastinal lymphadenectomy (VAMLA) followed by the right upper lobectomy with carinal resection and circular anastomosis between the trachea and the left main bronchus and reimplantation of intermediate bronchus into the right wall of the trachea proximal to the previous tracheobronchial anastomosis. Results. After a complex tracheo-bronchial resection several “non-surgical” early and delayed complications occured including acute respiratory distress syndrome, non-coronary myocardial infarction type II, thromboembolism of small branches of the pulmonary artery, pneumonia in the lower lobe of the left lung and osteomyelitis of the anterior segment of the 4th rib and perichondritis of the right 4th and 5th rib cartilages after adjuvant chemotherapy. We also demonstrate the methods used to treat complications in order to achieve good mid-term surgical results. Conclusion. Complicated central NSCLC is challenging both for surgical and non-surgical treatment. In carefully selected patients with complicated central NSCLC of the right upper lobe bronchus spreading to the main bronchus and trachea, radical organ-preserving surgery can be performed. Modern advances in thoracic surgery and аnaesthesiology, as well as the collaboration of doctors of various specialties in a multidisciplinary hospital, have made it possible to achieve good oncological and functional results 1.5 years after surgery.

From video-assisted mediastinoscopy (VAM) to video-assisted mediastinal lymphadenectomy (VAMLA) in a low- and middle-income country: surgical technique

From video-assisted mediastinoscopy (VAM) to video-assisted mediastinal lymphadenectomy (VAMLA) in a low- and middle-income country: surgical technique

The importance of alterations in innate lymphoid cell subsets in patients with non-small cell lung cancer and their role in tumorigenesis

Objective. Non-small cell lung cancer (NSCLC) is one of the leading causes of cancer-related morbidity and mortality. Diverse functions of innate lymphoid cells (ILCs) and NK cell subsets are investigated thoroughly in cancer immunotherapy. ILC and recently described NK cell subsets in NSCLC patients’ blood samples and tumor draining lymph nodes were investigated.
 Methods. The study included chemotherapy and/or radiotherapy-naive NSCLC patients with clinical stage T1-4N0-2M0 who underwent video-assisted mediastinal lymphadenectomy and 14 healthy controls. Mononuclear cells were isolated from peripheral blood of both groups and mediastinal lymph nodes of NSCLC patients. NK cells and ILC subsets were analyzed by flow cytometry.
 Results. Total NK cells are shown to be increased in peripheral blood of NSCLC patients compared to lymph nodes while the ratio of CD56dimCD16- exhausted NK cells is higher in lymph nodes than in blood samples of NSCLC patients. Compared to control group, peripheral blood ILC1 cells were lower in NSCLC patients, however ILC2 and ILC3 cells were significantly increased. However, mediastinal lymph nodes of NSCLC patients had decreased ratio of ILC2 and increased ratio of ILC3 cells than in peripheral blood of patients. NSCLC patients had significantly increased ratio of NKp44-ILC3 cells and decreased ratio of NKp44+ILC3 in lymph nodes. 
 Conclusion. Decreased ratio of ILC1 cells is an important indicator of impaired anti-tumoral response. Increased in the ratio of NKp44-ILC3 cells in NSCLC patients may potentially contribute to tumor progression. These findings highlight the distinct roles of ILCs, which play a pivotal role in the pathogenesis of lung cancer.

Efficiency and safety of video-assisted mediastinal lymphadenectomy in the treatment of non-small cell lung cancer

INTRODUCTION. A number of studies demonstrate the advantage of bilateral mediastinal lymphadenectomy in surgery of non-small cell lung cancer (nSCLC). For surgical approach to the opposite mediastinum for many years there were proposed sternotomy, video-thoracoscopy, and transcervical video-assisted interventions. In our practice, we use videoassisted mediastinal lymphadenectomy (VAMLA).The OBJECTIVE was to learn the efficiency and safety of VAMLA in surgery of NSCLC.METHODS AND MATERIALS. The study included the materials of examination and treatment of 102 patients with NSCLC. 102 patients were divided into 2 groups. In the 1st group (54 patients), VAMLA and lung resection were performed. In the 2nd group (48 patients): anatomical lung resection and systematic ipsilateral lymphadenectomy (SLD) were performed.RESULTS. The average number of remote lymph node stations in group 1 was (7.8±1.7); in group 2 – (4.5±1.2) (p<0.05). The average number of lymph nodes was 26±8.6 compared to (14.3±6) in both groups, respectively (p<0.05). «Occult» pN2-N3 metastasis was detected in 20 % (7/34) of patients of the group 1 and 6.5 % (2/31) of patients of the group 2 (p<0.05). The level of postoperative complications in both groups was 33.4 vs. 29.2 %, respectively (p>0.05). The duration of the postoperative day ((12.7±4.9) vs. (13.7±6.5)) and the duration of pleural drainage ((5.5±4.2) vs. (5.8±4.4)) did not differ in both groups (p>0.05).CONCLUSION. VAMLA is an effective and safe method for evaluating the pN stage of NSCLC. Performing VAMLA in left-sided NSCLC allows removing significantly more lymph nodes and stations in comparison with SLD available in VATS and thoracotomy, which increases the accuracy of postoperative N-staging. The use of the VAMLA in minimally invasive surgery of right-sided NSCLC may be promising in cases of high risk of «occult» pN3 lesion, but requires further study of the role of contralateral lymphatic dissection.

Video­assisted mediastinoscopic lymphadenectomy: technique and first results

Video-assisted mediastinal lymphadenectomy (VAMLA) has been introduced into our clinical practice as a surgical method for N-staging of non-small cell lung cancer (NSCLC) since 2017. In this paper, we presented the technique of VAMLA, analyzed our experience and compared the re- sults of the intervention with previously published data from other authors. Material and methods. The study ncluded materials from the examination and treatment of 56 patients with NSCLC who underwent VAMLA as part of the preoperative determination of the N-stage. Results. The average intervention time was 113±25 minutes. Each patient had 18.7±7.3; Me=18 (14–24) lymph nodes re- moved, from an average of 4.3±0.7 stations. The lymph nodes of groups 2R, 4R, 2L, 4L, and 7 were removed in 93, 100, 24, 100, and 100%, respectively. Biopsy of availa- ble nodes of group 10R was performed in 19.6% (11/56). 7 patients (12.5%) developed dysphonia after surgery. The learning curve of the new method in our experience was 30 operations. After VAMLA there were no missed me- tastases in the accessible areas of the mediastinum. Con­clusion. VAMLA is an effective and safe therapeutic and diagnostic intervention that demonstrates a consistently high volume of bilateral mediastinal lymphadenectomy.

Endobronchial ultrasonography with aspiration biopsy of the mediastinal lymph nodes and video-assisted mediastinoscopic lymphadenectomy in detecting "occult" N2-N3 metastasis in patients with non-small cell lung cancer

The condition of the mediastinal lymph nodes is an important factor in the selection of patients with non-small cell lung cancer for surgical treatment. Of particular concern are patients with not enlarged mediastinal lymph nodes according to CT-scan. The frequency of their “occult” pN2-N3 lesions can reach 22–41%. The aim of the study was to assay the possibilities of endobronchial ultrasono­graphy with transbronchial needle aspiration (EBUS/TBNA) of mediastinal lymph nodes and video-­assisted mediastinal lymphadenectomy (VAMLA) in detecting “occult” N2-N3 metastasis in patients with NSCLC. Materials and methods: 51 patients with proved NSCLC were included in this study. Inclusion criteria were: central tumor localization, peripheral cT2 tumors of more, cN1 stage, absence of mediastinal lymphadenopathy according to CT-scan. All patients performed EBUS/TBNA. Upon confirmation of the N2-N3 stage according to the data of a planned morphological study, the patient was referred to neoadjuvant therapy. With negative results, radical lung resection was performed. With inadequate results of an aspiration biopsy, VAMLA was performed with a frozen section study of one selective lymph node from stations 4R, 4L, 7. If their metastatic lesion was excluded in the same anesthesia, anatomical lung resection with systematic lymphodissection was performed. Results. The overall level of pN2-N3 lesion was 18.6% (9/51). Metastases to the mediastinal lymph nodes statistically prevailed in the group of patients with cN1 stage — 40% of cases (6/15). The fact of metastatic lesion of the lymph nodes did not depend on the adequacy of the aspiration biopsy. A metastatic lesion of the lymph nodes removed during VAMLA was revealed after the fact according to the results of a planned histological examination. The sensitivity of VAMLA was 71%, and PNV — 91%. Sensitivity and PNV of EBUS/TAB were 11% and 84%, respectively. Conclusion. cN1-stage is a factor of extremely high risk of "occult" metastasis. To exclude a regional lesion of not enlarged mediastinal lymph nodes, EBUS/TBNA is not enough. A necessary condition for the use of VAMLA in the framework of N-staging of patients with a high risk of “occult” metastasis is its use as an independent operation, with a mandatory planned study of all removed lymph nodes.

Supermediastinoscopies: where to fit and how to do on cancer practice

For years cervical mediastinoscopy was the main and only way to access the mediastinal status on lung cancer, but on the last decade new technologies had evolved either imaging, endoscopic or surgical procedures. Each one can give you very good results, but still have a different degree of certainty detecting anatomical extent of disease. Based on some published data and on our experience, we will address the use of video-assisted mediastinal lymphadenectomy (VAMLA) and trans-cervical extended maximal lymphadenectomy (TEMLA), named by Dr. Rami Porta as supermediastinoscopies, show procedures differences and where do we fit them on our practice.

Minimally invasive injection laryngoplasty in the management of unilateral vocal cord paralysis after video-assisted mediastinal lymph adenectomy.

IntroductionVideo-assisted mediastinal lymphadenectomy (VAMLA) is a valuable tool for invasive staging of the mediastinum. Unilateral vocal cord paralysis (UVCP) may occur in patients following VAMLA and may result in secretion retention within the lungs, atelectasis and associated infectious situations such as pneumonia. Minimally invasive injection laryngoplasty (ILP) is the treatment of choice in UVCP.AimTo evaluate the efficacy and success of acute minimally invasive injection laryngoplasty for patients with UVCP following VAMLA.Material and methodsPatients with the symptom of dysphonia following VAMLA were reviewed. All of the patients had UVCP according to the video laryngoscopy examination and had symptoms of aspiration and ineffective coughing. The Voice Handicap Index (VHI) questionnaire and maximum phonation time (MPT) were measured. Minimally invasive ILP was performed under general anesthesia with 1 cm of hyaluronic acid.ResultsThere were 525 consecutive non-small cell lung cancer (NSCLC) patients who underwent VAMLA. Five (0.95%) of the patients had UVCP and were suffering from aspiration during oral intake and ineffective coughing reflex. Maximum phonation time (MFT) was measured before and after ILP, and the results were 7.1 ±1.6 and 11.1 ±2.3 s, respectively (p < 001). The Voice Handicap Index-10 (VHI-10) score was 30.4 ±4.7 and 13.4 ±3.5 (p < 0.01), respectively. Patients underwent surgical lung resection. There was no morbidity or mortality.ConclusionsUnilateral vocal cord paralysis may occur as a complication of VAMLA. ILP may be an active tool for treating UVCP before anatomical lung resection to avoid potential morbidities. Successful management of this complication with multidisciplinary team work may encourage the use of VAMLA more frequently.

ED08.01 Surgery of Early-Stage NSCLC

ED08.01 Surgery of Early-Stage NSCLC

Surgical staging of lung cancer

Proper staging of lung cancer represents the basis for any stage-adapted and optimized treatment. This is today implemented in specialized centers mainly through the use of modern imaging methods and minimally-invasive measures. However, general thoracic surgery has a role not only in the therapeutic management of lung cancer, but offers additional staging information whenever endoscopic or interventional methods fail to achieve representative tissue biopsies of mediastinal lymph nodes or suspect lesions for conclusive diagnosis. The thoracic surgical armentarium comprises of cervical or extended mediastinoscopy, video-assisted mediastinal lymphadenectomy (VAMLA), anterior mediastinotomy (Chamberlain procedure) and video-thoracoscopy (VATS). Indications for any invasive diagnostic methods always have to respect a therapeutic benefit for the patient.

Hope for progress after 40 years of futility? Novel approaches in the treatment of advanced stage III and IV non-small-cell-lung cancer: Stereotactic body radiation therapy, mediastinal lymphadenectomy, and novel systemic therapy

Non-small-cell lung cancer (NSCLC) remains a leading cause of cancer mortality. The majority of patients present with advanced (stage III-IV) disease. Such patients are treated with a variety of therapies including surgery, radiation, and chemotherapy. Despite decades of work, however, overall survival in this group has been resistant to any substantial improvement. This review briefly details the evolution to the current standard of care for advanced NSCLC, advances in systemic therapy, and novel techniques (stereotactic body radiation therapy [SBRT], and transcervical extended mediastinal lymphadenectomy [TEMLA] or video-assisted mediastinal lymphadenectomy [VAMLA]) that have been used in localized NSCLC. The utility of these techniques in advanced stage therapy and potential methods of combining these novel techniques with systemic therapy to improve survival are discussed.

Comparison of video-assisted mediastinoscopy and video-assisted mediastinoscopic lymphadenectomy for lung cancer

We compared the efficacy and complications of video-assisted mediastinoscopy (VAM) and video-assisted mediastinal lymphadenectomy (VAMLA) for mediastinal staging of lung cancer. Between March 2006 and July 2008, a total of 157 patients with non-small-cell lung cancer (NSCLC) underwent VAM (n = 113, 72%) or VAMLA (n = 44, 28%). We studied them retrospectively. Data for the operating time, node stations sampled/dissected, number of biopsies, and the patients who were pN0 by mediastinoscopy and underwent thoracotomy were collected. The false-negative rate was calculated. Demographics and operative complications were analyzed. The overall complication rate was 5.7% (n = 9). The most common complication was hoarseness (n = 8). Complications were seen significantly more often after VAMLA than after VAM (11.3% vs. 2.6%, P = 0.04). There were no deaths. The mean number of removed lymph nodes (8.43 ± 1.08) and the station numbers (4.81 ± 0.44) per patient were higher with VAMLA than with VAM (7.65 ± 1.68, P = 0.008 and 4.38 ± 0.80, P = 0.001, respectively). The mean operating time was 44.8 ± 6.6 min for VAM and 82.0 ± 7.8 min for VAMLA. Patients diagnosed as pN2 numbered 9 in the VAMLA group and 27 in the VAM group. The patients diagnosed as pN0 with mediastinoscopy then underwent thoracotomy (VAM 77, VAMLA 32). When they were investigated for the presence of mediastinal lymph nodes, there were three (3.8%) false-negative results in the VAM group and five (15.6%) in the VAMLA group. Sensitivity, accuracy, and negative predictive values for VAM and VAMLA were 0.90/0.97/0.96 and 0.64/0.87/0.84, respectively. VAMLA was found to be superior to VAM with regard to the number of stations and lymph nodes. Complications after VAMLA were common. The sensitivity and NPV of VAM for mediastinal staging are significantly higher than those of VAMLA.

Incisiones y vías de abordaje quirúrgicas

The correct choice of the incision to the chest is essential for surgical success and a favorable postoperative course. The route of access to the thorax must be adapted both to the disease and to the thoracic surgeon's experience, striking a balance between aggressiveness and the safety of the technique. This article describes the characteristics of surgical incisions, including classical thoracotomy, sternotomy and its variants, thoracoscopy and minimally-invasive surgery. The distinct techniques used to explore mediastinal lymphatic areas, including video-assisted mediastinal lymphadenectomy and transcervical extended mediastinal lymphadenectomy, are also described.

The Safety and Usefulness of Combined Video-Assisted Mediastinoscopic Lymph Adenectomy and Video-Assisted Thoracic Surgery Lobectomy for Left-sided Lung Cancer

Background: The use of video-assisted thoracic surgery (VATS) to perform major pulmonary resection with systematic node dissection (SND) for lung cancer by is commonly used in clinics. However, the feasibility of SND by VATS remains controversial. Video-assisted mediastinal lymphadenectomy (VAMLA) increases the quality of mediastinal lymph node staging in lung cancer. The video-mediastinoscope allows systematic lymphadenectomy by bimanual preparation. This study was conducted to assess safety and usefulness and clinical feasibility of VAMLA expanding Linder-Dahan mediastinoscope with VATS lobectomy for left sided lung cancer. Material and Method: Between February 2004 to April 2008, a total 50 patients who underwent VATS lobectomy for left sided lung cancer were analyzed retrospectively. Thirty patients (group A) underwent VAMLA followed by VATS lymphadenectomy and 20 patients (group B) underwent VATS lymphadenectomy for SND. Result: There were no statistical differences in operation times, chest tube indwelling times, or hospital days between the 2 groups. The number of dissected total nodes (p=0.001) and N2 nodes (p=0.013) were higher in group A than in group B, but there was no difference in N1 nodes. Postoperative complications included 2 prolonged air leakages (≥10 days) in each group, one pneumonia in group A, and one vocal cord palsy in group B. There were no early operative mortalities. Conclusion: Mediastinal staging of resectable lung cancer is performed by VAMLA. This new technique is the basis for VATS lobectomy particularly for left-sided lung cancer, because a higher percentage of mediastinal lymph nodes undergo complete resection using VAMLA.

Video-assisted mediastinoscopic lymphadenectomy (VAMLA)--a method for systematic mediastinal lymphnode dissection.

Video-assisted mediastinal lymphadenectomy (VAMLA) increases quality of mediastinal lymph node staging in bronchial carcinoma. The video-mediastinoscope allows systematic lymphadenectomy by bimanual preparation. Complete bilateral resection of lymph nodes in stations 1, 2, 3, 4 and 7 (Naruke) can safely be done after visualization of limiting structures (trachea, main bronchi, oesophagus, pericardium, pulmonary artery, aorta, upper vena cava and azygos vein). In this initial study, we compared histopathological findings from VAMLA with final lymph node staging from subsequent thoracotomy. Between January 2001 and December 2001, 25 patients were operated by VAMLA (among 162 mediastinoscopies), two patients for diagnostic purposes and 23 for staging of bronchial carcinoma. Eighteen patients underwent subsequent thoracotomy for tumor resection and systematic lymphadenectomy. Pathological findings were reviewed. In VAMLA, lymph node dissection of station 2R, 2L and 4R was achieved in 96, 28 and 92%, respectively, whereas resection of lymph nodes in station 7 and 4L was performed in 100%. Other locations were dissected in 44%. A mean of 8.6 lymph nodes were removed in each patient. No residual lymph node tissue was found in the subcarinal compartment at open surgery. When comparing histopathological staging from VAMLA with final pathology, there were no false negative results. Seventeen patients who had N0 disease at VAMLA proved to be N0 or N1 at thoracotomy, one patient diagnosed as N2 at mediastinoscopy had N2 disease at final pathology. The only complication observed in VAMLA was a blood loss of >100 ml in 12% of patients without need for transfusion or surgical intervention. Mediastinal lymph node staging is improved by VAMLA. A systematic lymphadenectomy is performed bimanually through the video mediastinoscope. The number of lymph nodes removed is doubled compared to standard mediastinoscopy. There were no false negative results at final pathology. This new technique presents the basis for video-assisted thoracic surgery (VATS) lobectomy because complete resection of the mediastinal lymph nodes can be achieved by VAMLA. Potential complications of VAMLA such as injury of major mediastinal vessels, airways, pneumothorax or recurrent laryngeal nerve injury indicate the need for a full thoracic surgical infrastructure.